What is children's mental health care?

 Patricia Wen's front page story Children's Access to Mental Health Care is Growing, in which she describes the "co-location" of mental health care services in pediatric practices, brought me back to the summer of 2011 when I attended a meeting of a working group of the Massachusetts Chapter of the American Academy of 
Pediatrics (MCAAP.) The task of this working group, a subgroup of the MCAAP task force on mental health care in pediatrics, was to address the need for collaboration between pediatricians and mental health professionals in caring for children. At the meeting individuals described different models.



One pediatrician, a man who has been in practice for over 30 years in a large group with 15 pediatricians and 10 nurse practitioners, was invited to present his model, held up as an example of an innovative and workable model. This is what he said. 



First, clinicians went in groups of 4 to attend conferences run by a prominent MGH child psychiatrist. Then another child psychiatrist started bi-weekly phone consultation with the group as a whole. 



Now, this pediatrician said with pride, the clinicians in his practice are comfortable " treating 80% of ADHD, anxiety and depression." They were hiring a social worker, whose job it would be not to do therapy, but rather to "make sure patients are taking their medications and refilling prescriptions." 



In other words, mental health care, at least for this doctor and his large group, is equivalent to prescribing psychiatric medication.



This practice is paid by Blue Cross Blue Shield under the model of AQC(alternative quality care) global budget. If the practice overspends they pay the insurance company and if they underspend they split the profit. In addition, if they practice "quality care" as defined by the insurance company, they receive more money. One measure of quality is follow up every four month for ADHD and compliance with psychiatric medication.



Another pediatrician offered an alternative model of collaborative care. She described a close personal relationship with a psychologist, who was also at the meeting. She described how, through confidential voicemail and email, they spoke frequently about their most challenging patients, working closely to provide care, and in doing so keeping a number of patients out of the hospital.



 In a sense the people who presented these two models were speaking completely different languages, one in which mental health care equals medication and another in which mental health care equals providing a "holding environment" through relationships. Unfortunately the second model is at risk of being overpowered, under the influence of the pharmaceutical and health insurance industries, by the first model. 

Our best hope for fighting this trend, I believe, lies in maintaining a focus on prevention- on promotion of healthy social-emotional development in early childhood through relationship-based interventions. 

In the Early Childhood Social Emotional Health Program at Newton-Wellesley Hospital I collaborate closely with pediatricians who refer infants, toddlers and preschoolers. I work with children with a range of issues including, but not limited to colic, sleep problems, separation anxiety and explosive behavior. I work with parents and child together. Another program, Project Climb at Colorado Children's Hospital, described in the article  Providing Perinatal Mental Health Care in Pediatric Primary Care integrates infant mental health services in to primary care.

This is a role that primary care clinicians can and should embrace. In a previous post I wrote about a proposed model of including a professional who is experienced with working with parents and infants together in every primary care practice. This person could work with parent-infant pairs when parents are struggling with postpartum depression or anxiety, and/or an infant is fussy/colicky, or in other ways "dysregulated."   

 Research at the interface of developmental psychology, neuroscience and genetics offers extensive evidence that supporting early parent-child relationships is an essential part of promoting healthy  emotional development.

This important aspect of children's mental health care was not mentioned in Wen's article. Instead, the focus was on treatment of "ADHD" and other DSM diagnoses in collaboration with MCPAP- the Massachusetts Child Psychiatry Access Project- whose role Wen describes: 

The Massachusetts Child Psychiatry Access Project provides a hotline for pediatricians to call for consultations with psychiatrists, especially for help with the complexities of prescribing psychotropic drugs. 

The co-location model described in Wen's article is an excellent one. Pediatricians have relationships with children and families that are invaluable. They are important collaborators with mental health professionals.  Parents and young children can be found frequently in a primary care office.  However, any conversation about "co-location" of children's mental health care is lopsided and incomplete without a discussion of preventive care focused on infancy and early childhood. 

  

Ode to joy: moments of parent-child connection

A friend and colleague recently asked if I thought joy was an emotion or a state. Without pause, I responded that it was a way of being fully present.

Early the next morning I was at Starbucks writing to another colleague about a case from my pediatrics practice for a book we are writing about parenting. I was describing a scene with a mother and 4-month-old son.  He had been a very challenging newborn who cried all the time, and she had struggled with postpartum depression. In my office they gazed adoringly at each other with huge smiles of delight.  I wrote, "There was pure joy in their relationship."

I glanced up from my writing to see yet another scene. A father was calmly telling his two-year-old daughter that she needed to hold his hand when they crossed the street. He was negotiating his coffee and her juice while she repeatedly wriggled away. "I can carry you or you can hold my hand, " he said. No go. She reached out to him for an instant, but again dodged his reaching hand. "Big girls hold hands crossing the street." It seemed this would work as she again reached out, but again changed her mind. Then somehow very gracefully he switched his beverages and offered his other hand. "Do you want to hold this one?" This was the magic needed. It seemed as if she had to have some say before she would temporarily relinquish her growing independence.  I watched this big tall daddy and his little girl walk across the street hand-in-hand. Another moment of joy, both for them and for me.

Interestingly, the day before another colleague had invited me to speak at a conference for early childhood professionals about the "magic of the moment" in our work supporting early parent-child relationships.

The dictionary definition of joy actually describes it as either an emotion or a state. But for me the word captures not only a state, but a state of connection, with another person, with nature, or, to quote a famous book title, "Life, the Universe and Everything."

All of these experiences served as a reminder to keep the focus, in my work with families and young children, and in my life in general, on striving for these moments of joy, of meaningful connection. These tiny moments all strung together lead to, borrowing two other words from the title of that upcoming conference, resilience and peace. 

Connecting the dots to discover the cause of "ADHD"

A reader of my previous post asked how I "connect the dots" from supporting newborns and parents to "ADHD" treatment. He states that, "trying to figure out the cause will not help any kid today." This comment motivated me to clarify what I mean by cause, as I think finding out the cause will help every kid today.

What I mean by "finding out the cause" is to give parents the space and time to tell their story, to make sense of their child's symptoms.  The aim is not to determine if the child has enough symptoms to meet diagnositic criteria for a DSM defined disorder, but rather to support  parents' efforts to find a coherent narrative. It involves starting with at least 1-2 full hour visits with both parents.  I put "ADHD" in quotes because by giving the symptoms a name, as in "ADHD evaluation" we narrow our thinking before we even start. Ideally we listen to the family's story with an open minded curiosity.

The story often starts with a fussy or colicky baby. Even before this, there may have been stress in pregnancy which is known to be associated with advanced motor development and behavioral dysregulation in the newborn. Postpartum depression and/or anxiety may have been present. Supporting a dysregulated baby is particularly challenging when a parent is affected by depression and/or anxiety. These babies often continue to have symptoms of dysregulation into the toddler and preschool years, with frequent tantrums, "not listening" or "explosive behavior." There is often a strong family history of "ADHD," substance abuse or other mental illnesses. This history is closely linked with current relationships. For example, if one parent has "ADHD," the child's behavior may be especially dysregulating for that parent. One parent who does not have "ADHD" may blame the other parent, resulting in marital discord. The child may have significant sensory processing challenges. The child may be developmentally immature and the youngest in a structured preschool program. Sleep disurbance on the part of both parent and child has a significant role to play in development of symptoms.  There are as many variations to this narrative as there are families. Clinicians also need to be attentive to the fact that child maltreatment is a rare cause of "ADHD"  that we do not want to miss, and must be considered.

 Once parents have the opportunity to make sense of their child's symptoms,  "what to do" follows naturally. Medication may, in a few cases, be indicated, particularly if a child's self esteem is suffering due to academic demands. But more often than not, the "what to do" is elsewhere. For example, a parent may need to do his own therapy to address troubled past relationships. A parent may take up yoga to manage the dysregulation her child's symptoms precipitate, so that she can remain calm in the face of his difficulties. Sleep disruptions are often part of the story and must be addressed. Marital counselling may be necessary. A good occupational therapist, who helps the family to manage the child's unique challenges in the context of relationships, can be invaluable.

Time, space and a nonjudgmental listener are essential first step in evaluation of any child with behavioral symptoms. The "why" must come before the "what." Then the "what to do"will follow naturally.

Evidence mounts that our current approach to "ADHD" is way off base

An NIH funded study published last week in the Lancet revealed that five major mental health disorders- ADHD, autism, bipolar disorder, depression and schizophrenia- share genetic roots. The authors state that their findings blur diagnostic categories. They write:

These results provide evidence relevant to the goal of moving beyond descriptive syndromes in psychiatry, and towards a nosology informed by disease cause.

Epigenetics, or the environmental influence on gene expression, must immediately be brought in to any discussion of these important findings. "Cause" is related to a complex interplay between genetic risk and environmental effects.

Another study on ADHD published this week points to the problems inherent using this oversimplified diagnostic category. The study, published in Pediatrics, showed that not only do symptoms of ADHD persist into adulthood in 30% of cases, but there is also a significant amount of "co-morbidity," including these alarming statistics:

The study also found the risk for suicide was nearly five times higher among those diagnosed with ADHD than in the comparison group, and nearly 3% of study participants were in jail when recruited for the adult portion of the study.

A review of the study published in USA today includes this telling line:

Symptoms[of ADHD] can be controlled by a combination of behavioral therapy and medication. 

Maybe the reason that so many people have such poor outcomes is that we are neglecting to understand the underlying cause of the problem and instead simply labeling and "managing" symptoms. These dismal long-term results, along with the similarly dismal results reported in the preschool ADHD study showing that 90 percent of children had signficant symptoms at 6 year follow up, state loud and clear that the way we approach what we are now calling "ADHD"  is not working. We need to do something dramatically different from the current standard of care.

What we are calling "ADHD" is a constellation of symptoms that represent problems with regulation of attention, behavior, and emotion. The term itself gives the illusion that we know the specific biological mechanism in the way that we know how lack of insulin causes diabetes. This is however, far from true.

As the first study I refer to indicates, we are just beginning to learn about the underlying biology of mental illness, and those findings suggest that "ADHD" may be an artificial construct.

My clinical experience tells me that these genes they have described may be functionally related to sensory processing.  Problems with sensory processing seem to be common to many diagnostic categories for mental illness that we currently use. However, children develop the capacity for self-regulation in the context of relationships. Identifying the problematic gene is only part of the answer. Understanding and addressing the environmental risk is the other.

If we consider the interplay of genetics and environment, then a third study published last week, this one also in Pediatrics, will point us in the direction of meaningful preventive intervention. This study identified the problem of postpartum anxiety, concluding that:

Postpartum state anxiety is a common, acute phenomenon during the maternity hospitalization that is associated with increased maternal health care utilization after discharge and reduced breastfeeding duration. 

Given what we already know about the risk of psychiatric disorders in children of parents struggling with depression,  these findings only increase the urgency of focusing our resources on supporting parent-infant pairs. We need to help set development in a healthy direction from the start.  Genetic vulnerabilities are present at birth, and if we devote maximum resources to supporting the environment, then we may significantly decrease the risk of those vulnerabilities manifesting as psychiatric illness.